TORONTO — Recent municipal elections in Toronto show signs of a shift away from unwavering support for supervised injection sites as a primary harm reduction strategy. The change comes as medical research points to brain injury from overdose as a major factor in chronic homelessness, complicating the "Housing First" approach. In Toronto-Danforth, newly elected councillor Sara Ehrhardt said the city must work with other governments to "look at evidence-based approaches for harm reduction." She added, "that might not look like supervised injection sites right now." In Parkdale-High Park, councillor Diana Chan McNally, a former frontline worker, also appeared to soften her position on the sites while campaigning.
A resident from Parkdale, who requested anonymity due to intimidation campaigns, said Chan McNally distanced herself from a local site when discussing neighbourhood concerns. The resident said Chan McNally suggested that providing sterile pipes and needles alone was not a long-term solution and that building housing would address the root problems. Chan McNally did not respond to a request for comment on the exchange. Her campaign, and that of mayor Olivia Chow, were supported by Progress Toronto, an organization whose city council issues list focused on "affordable housing" and did not mention encampment rights. The emerging political shift coincides with medical findings that challenge the sufficiency of housing alone for a significant portion of the homeless population. An article in the Canadian Medical Association Journal by Dr. Monty Ghosh cites studies finding individuals experiencing chronic homelessness have "high rates of cognitive and functional impairment," often from brain injuries caused by overdose. Ghosh estimated to the Globe and Mail that between 20 per cent and 30 per cent of the homeless population suffer from severe cognitive impairment that leaves them unable to manage their own housing or safety.
Ghosh's article calls Housing First "necessary but insufficient" for this group, who require what he terms "intensive housing." This model is modelled after long-term care, not psychiatric institutionalization, and involves secure or semi-secure units with around-the-clock staff including nurses and health care aides. Ghosh and The Canadian Alliance to End Homelessness are seeking $2 billion from the federal government to build 6,250 intensive housing units across the country. The recent federal budget earmarks $10 billion for 25,000 supportive and transitional homes, but it is not yet clear where intensive housing fits into the plans.
Evidence from other jurisdictions illustrates the challenge. In Victoria, B.C., units opened to accommodate about 80 people living in downtown encampments, but less than half accepted the offer of housing. Victoria Police Sgt. Jeremy Preston said the problem was that many were "unhousable," noting that even low bars for supportive housing, like not lighting fires or threatening staff, were too high for some. An expert in Alberta estimated that 5 to 15 per cent of the homeless encampment population may be candidates for involuntary treatment initiatives.
Combined with the estimated 20 to 30 per cent needing intensive housing, this suggests nearly half of the country's homeless population may require options beyond standard supportive housing or voluntary harm reduction. The role of acquired brain injuries from overdose is gaining recognition. Two months ago, a letter in the journal Addiction, co-authored by B.C.'s Chief Scientific Advisor for Psychiatry, Toxic Drugs and Concurrent Disorders, Dr. Daniel Vigo, and others, argued for "brain injury-informed opioid treatment." The letter cited numerous studies on the consequences of overdose.